{"paper_id":"5eb73fb3-59f6-46d6-a428-cda423af738d","body_text":"International Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR250349433 Volume 7, Issue 3, May-June 2025 1 \n \nThoracic Endometriosis Presenting as \nCatamenial Pneumothorax: A Case Report and \nSurgical Management with Vats and \nDiaphragmatic Repair \n \nDr. G Anantha Lakshmi1, Ch. V . Sai Priyanka2, Unnati Hiremath3 \n \n1Professor & Head of Department, Pharm D, Sri Venkateshwara College of Pharmacy, Madhapur, Hitech \nCity Road-86, Hyderabad, India \n1,2,3Sri Venkateshwara College of Pharmacy, Madhapur, Hitech City Road-86, Hyderabad, Telangana-81, \nIndia \n \nABSTRACT: \nCatamenial pneumothorax is a rare form of spontaneous pneumothorax that occurs in temporal association \nwith menstruation, typically within 72 hours of the onset of menses. It is the most common manifestation \nof thoracic endometriosis syndrome, a condition characterized by the presence of functional endometrial \ntissue within the thoracic cavity. Although underdiagnosed, it primarily affects women of reproductive age \nand is often linked to diaphragmatic defects, pleural implants, or intrathoracic endometrial lesions. We \nreport the case of a 32 -year-old woman with recurrent right -sided pneumothorax coinciding with her \nmenstrual cycle and a background suggestive of pelvic endometriosis. Clinical suspicion led to a \nmultidisciplinary evaluation, and the patient un derwent Video-Assisted Thoracoscopic Surgery (V ATS), \nwhich revealed diaphragmatic fenestrations and pleural endometrial lesions. Concurrent diagnostic \nlaparoscopy identified pelvic endometriosis, and histopathology confirmed thoracic endometriosis. \nSurgical excision of ectopic tissue was followed by initiation of hormonal therapy to prevent recurrence. \nThe patient had an uneventful recovery and remained symptom-free at follow-up. This case highlights the \nimportance of considering catamenial pneumothorax in differential diagnoses for spontaneous or recurrent \npneumothorax in women of childbearing age. Recognition of thoracic endometriosis requires a high index \nof suspicion and is best managed through an interdisciplinary approach combining thoracic surgery, \ngynecology, and pathology. Early diagnosis and coordinated treatment —incorporating surgical \nintervention and hormonal suppression—are essential to achieving symptom control and reducing the risk \nof recurrence. \n \nKeywords: Catamenial pneumothorax, Thoracic endometriosis, V ATS, Diaphragmatic fenestration, \nPleurodesis, Endometriosis \n \nINTRODUCTION: \nCatamenial pneumothorax is a rare clinical entity predominantly affecting women between the ages of 30 \nand 40, often underdiagnosed that presents a unique intersection between pulmonology and gynaecology. \nIt refers to the spontaneous collapse of the lung occurring in close temporal association with the menstrual \n\n \nInternational Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR250349433 Volume 7, Issue 3, May-June 2025 2 \n \ncycle—typically within 72 hours of menstruation onset. The cyclic hormonal changes associated with \nmenstruation lead to inflammation, bleeding, or tissue breakdown at these sites, which may result in \npneumothorax, hemothorax, or hemoptysis. Though this ent ity may not be the first consideration in a \ndifferential diagnosis for spontaneous pneumothorax in women, it is an important one, especially for \nwomen in their reproductive years. The condition is frequently associated with thoracic endometriosis \nsyndrome (TES), which includes pleural, diaphragmatic, or pulmonary parenchymal endometrial \nimplants. While endometriosis is a common gyn aecological condition, thoracic involvement is less \nfrequent and often overlooked. The subtle and nonspecific nature of symptoms—ranging from mild chest \ndiscomfort to acute respiratory distress—can delay diagnosis and treatment. For many patients, symptoms \nrecur over months or even years before a correct diagnosis is made. Moreover, due to the anatomical \npreference for right -sided involvement, many cases may be misclassified as idiopathic right -sided \npneumothorax without further investigation. \nSeveral mechanisms have been proposed to explain the pathophysiology of this condition. The most \nwidely accepted theory is the transdiaphragmatic passage of endometrial cells from the pelvis into the \nthoracic cavity. This is thought to occur through small congenital or acquired defects in the diaphragm, \nparticularly on the right side, which allows endometrial tissue to migrate and implant on the pleura, lung \nparenchyma, or diaphragm itself. \nAnother proposed mechanism involves hematogenous or lymphatic dissemination, where endometrial \ncells travel through the bloodstream or lymphatic system to reach thoracic structures. Once implanted, \nthese ectopic endometrial tissues undergo cyclical changes  in response to hormonal fluctuations during \nthe menstrual cycle, leading to local inflammation, necrosis, or hemorrhage, which can ultimately result \nin alveolar rupture and air leakage into the pleural space. \nIn addition, prostaglandin -mediated effects may contribute by causing bronchospasm or vasospasm, \nincreasing the fragility of the alveolar -capillary barrier and predisposing the lung to rupture. Structural \nalterations in the diaphragm, such as fenestrations  or blebs, may also predispose patients to the \ndevelopment of pneumothorax during menstruation due to increased intrathoracic pressures and hormonal \ninfluences on connective tissue. \n \nCASE REPORT: \nA 31-year-old woman with a long-standing history of severe dysmenorrhea since menarche, progressively \nworsening over the past 6–7 years, her menstrual cycles were regular (6–9/26–28 days), accompanied by \nheavy bleeding lasting 6–7 days with passage of clots. She had a known diagnosis of fibroid uterus and a \n1 cm haemorrhagic/endometriotic cyst. A prior laparoscopy had been scheduled but was abandoned \nintraoperatively due to dense pelvic adhesions. Now she presented with complaints of shortness of breath \nand headache for 7 days, along with low back and neck pain for 2 months . She also reported lower \nabdominal pain associated with vomiting, generalized body aches during menstruation, and increased \nbowel and bladder frequency. On examination, vital signs were within normal limits: PR 92 bpm, RR 24 \nbpm, SpO₂ 96% on room air, BP 110/80 mmHg. Chest auscultation revealed decreased breath sounds on \nthe right side. High-resolution computed tomography (HRCT) of the chest showed a moderate right-sided \npneumothorax with complete collapse of the right upper and middle lobes and partial collapse of the right \nlower lobe. Laboratory investigations revealed Hb 11.5 g/dL, TLC  16,400/mm³, and platelets 2.41 \nlakh/mm³. She was admitted and managed with oxygen supplementation at 2 –4 L/min. Bronchoscopy \nrevealed normal upper airways and trachea, with collapse of the right upper and middle lobes due to \n\n \nInternational Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR250349433 Volume 7, Issue 3, May-June 2025 3 \n \npneumothorax. A 2D echocardiogram showed an ejection fraction of 63%, mild pulmonary arterial \nhypertension, and no regional wall motion abnormalities. MRI of the spine showed mild disc bulge at C3-\nC4 to C5-C6 and L5-S1 disc desiccation with central protrusion causing bilateral foraminal narrowing. In \nview of the patient’s past history of endometriosis and prior hysteroscopy,  a diagnostic laparoscopy was \nplanned. A provisional diagnosis of right -sided catamenial pneumothorax was considered based on the \nclinical presentation and temporal association with the menstrual cycle. A thoracic surgery consult \nconfirmed the diagnosis, and surgical management  was planned. The patient received a comprehensive \npharmacological regimen tailored to address both perioperative needs and underlying pathophysiology  \nduring her hospital stay . Inj. Pantoprazole 40 mg once daily was administered as prophylaxis against \nstress-related mucosal injury and to reduce gastric acid secretion  from day 1 to day 10 . Paracetamol 1 g \nthree times daily was prescribed for antipyretic and analgesic effects, ensuring consistent pain control  \nfrom day 1 to day 10. To manage neuropathic pain and enhance overall pain modulation, Amitriptyline 10 \nmg once daily was included  from day 1 to day 10 . Tramadol 50 mg twice daily and a Buprenorphine \ntransdermal patch (single application) provided opioid -based analgesia for moderate to severe pain, \nensuring sustained relief post -surgery. Progesterone 10 mg twice daily was initiated to suppress ovarian \nhormonal activity, thereby minimizing the risk of recurrence of endometriotic lesions. Ondansetron 8 mg \ntwice daily was used to prevent nausea and vomiting associated with both anaesthesia and opioid use. \nTranexamic acid 500 mg twice daily was prescribed to minimize post operative bleeding through \nantifibrinolytic action. To prevent infection, Cefoperazone–Sulbactam 1.5 g twice daily was administered \nas broad-spectrum antibiotic coverage. Lactulose 30 ml once daily was provided to prevent opioid-induced \nconstipation and su pport gastrointestinal function. This multi -drug regimen reflects a multidisciplinary \nstrategy aimed at pain control, hormonal suppression, infection prophylaxis, and optimal postoperative \nrecovery. \nThe patient underwent diagnostic V ATS (Video Assoisted Thoracoscopic Surgery) with diaphragmatic \nendo-excision, primary repair, apical pleurectomy, and talc pleurodesis. Intraoperatively, a 10 mm port \nwas placed 4 cm below the xiphisternum, along with two 5 mm right lateral ports and intercostal incisions \nat the 5th and 9th intercostal spaces for thoracic access and ICD placement. Thoracic findings included a \nfenestration on the right hemidiaphragm adjacent to the central tendon, which was excised and repaired. \nApproximately 100 ml of haemorrhagic pleural fluid was drained. Endometr iotic nodules were excised \nfrom the apical pleura, chest wall, superior vena cava, and both diaphragmatic surfaces. A minor apical \npleural leak was noted. Talc pleurodesis with 3 g of Steritalc (sterile, asbestos-free, endotoxin-free talc for \ninstillation in the case of malignant pleural effusion or pneumothorax) was performed, and a 28F ICD was \ninserted. Simultaneously, diagnostic laparoscopy was performed. Findings included complete obliteration \nof the pouch of Douglas due to bowel adhesions, sigmoid mesocolon and rectum adherent to the posterior \nuterine surface, and bluish endometriotic lesions on both diaphragmatic surfaces. A 1x1 cm subserosal \nmyoma on the uterine fundus was also identified and excised. The Enzian classification was as follows \n• Peritoneum (P0): No superficial peritoneal lesions \n• Ovaries (O0/0): No endometriomas noted in either ovary \n• Tubes (T0/0): Bilateral fallopian tubes were normal \n• Rectovaginal space (A3): Complete obliteration of the pouch of Douglas due to bowel adhesions to \nthe posterior uterine surface \n• Ligaments (B0/0): No abnormalities or nodules in the uterosacral or cardinal ligaments \n• Rectum (C0): No rectal nodules observed \n\n \nInternational Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR250349433 Volume 7, Issue 3, May-June 2025 4 \n \n• Diaphragm (F(D)): Bluish endometriotic spots measuring 1 × 1 cm on the right side and 1.5 × 1.5 cm \non the left side; right diaphragmatic fenestration 5 × 5 mm \n• Thorax (F(T)): Endometriotic nodules (1 × 1 cm) noted in apical pleura and superior vena cava; an \nadditional 5 × 5 mm nodule seen on the chest wall \n• Sigmoid colon and rectum: Adherent to the posterior uterine surface and fundus \n• Subserosal uterine myoma: A 1 × 1 cm subserosal fibroid was excised from the left fundus \nStaging: \n• ENZIAN Classification: P0 O0/0 T0/0 A3 B0/0 C0 F(D)(T) \n• AAGL Stage: 2 (Score: 9) \nSpecimens sent for histopathological examination included diaphragmatic endometriotic lesions, thoracic \npleural nodules, and the uterine myoma. Final results confirmed endometriotic pathology. Postoperatively, \nthe patient’s recovery was uneventful. The ICD was removed. The patient showed significant symptomatic \nimprovement and was discharged in stable condition. \nAt discharge, the patient was prescribed the following medications - Liquid Paraffin + Milk of Magnesia \n15 ml once daily for constipation; Gabapentin NT 200 mg once daily for neuropathic pain and migraine \nprophylaxis; Esomeprazole+ domperidone 40 mg once da ily before breakfast for acid suppression; \nCefpodoxime + Clavulanic Acid 325 mg twice daily for 5 days as antibiotic therapy; Paracetamol 650 mg \nthrice daily for 3 days for pain relief; Norethisterone 10 mg twice daily for hormonal regulation and \nmanagement of abnormal uterine bleeding; and Zincovit once daily as a nutritional supplement. The \npatient was also advised to continue incentive spirometry exercises to support respiratory recovery. \n \nDISCUSSION: \nCatamenial pneumothorax presents a clinical challenge not only because of its rarity but also due to the \noverlapping symptomatology with more common pulmonary conditions. Its association with the menstrual \ncycle often goes unnoticed unless a detailed menst rual history is taken, and many women are left \nundiagnosed or misdiagnosed for prolonged periods. This case reinforces the critical need for heightened \nclinical suspicion, particularly in women of childbearing age who present with recurrent or right -sided \npneumothorax. \nIn this patient’s case, the intraoperative findings of diaphragmatic fenestrations and pleural endometriotic \nnodules provided compelling evidence of thoracic endometriosis. Her previous diagnosis of pelvic \nendometriosis and the cyclical nature of her sympt oms further strengthened the diagnosis. Interestingly, \nthe presence of endometrial tissue near the superior vena cava and chest wall underscores the potential for \nwidespread thoracic involvement, beyond the more commonly observed diaphragmatic and pleural \nsurfaces. The role of video-assisted thoracoscopic surgery (V ATS) cannot be overstated in the management \nof catamenial pneumothorax. It allows for direct visualization of thoracic pathology, excision of \nendometrial implants, repair of diaphragmatic defects , and definitive treatment via pleurodesis. \nAdditionally, concurrent laparoscopic evaluation of the pelvis ensures a comprehensive approach to \nendometriosis management, tackling both thoracic and abdominal disease burdens. Another important \naspect of management is the consideration of hormonal therapy postoperatively to suppress ovulation and \nreduce the likelihood of recurrence. Gonadotropin -releasing hormone (GnRH) analogs, oral \ncontraceptives, or progestins are often employed in long -term care strategies.  While surgical correction \naddresses immediate structural issues, long-term disease control often requires hormonal therapy. \n\n \nInternational Journal for Multidisciplinary Research (IJFMR) \n \nE-ISSN: 2582-2160   ●   Website: www.ijfmr.com       ●   Email: editor@ijfmr.com \n \nIJFMR250349433 Volume 7, Issue 3, May-June 2025 5 \n \nHormonal treatment plays a critical role in suppressing the cyclical hormonal stimulation of ectopic \nendometrial tissue, thereby reducing the likelihood of recurrence. \nHence, catamenial pneumothorax should be part of the differential diagnosis in women with unexplained, \nrecurrent pneumothorax, especially if there is any correlation with their menstrual cycle or a history of \nendometriosis. Early recognition and a multidis ciplinary treatment approach are vital in reducing \nmorbidity and preventing recurrence. \n \nCONCLUSION: \nCatamenial pneumothorax remains a rare but clinically significant condition that warrants heightened \nawareness among healthcare professionals. This case emphasizes the necessity of considering thoracic \nendometriosis in reproductive -age women presenting wit h recurrent or spontaneous pneumothorax, \nparticularly when symptoms correlate with the menstrual cycle. Early recognition and a coordinated, \nmultidisciplinary approach—utilizing both thoracic and pelvic surgical evaluation —can lead to accurate \ndiagnosis, effective treatment, and prevention of recurrence. Enhancing clinician awareness across \nspecialties is essential to reduce diagnostic delays and improve outcomes for patients affected by this \nunderdiagnosed disorder. \n \nREFERENCES: \n1. Alifano M, Trisolini R, Cancellieri A, Regnard JF. 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